Does Rational Medicine Fulfill these conditions

Such a Therapeutics must be necessarily based on a theory which is a generalization, and which therefore overlooks those phenomena of a given case which are peculiar to the individual patient and takes congizance only of those phenomena which are common to a great number of cases.

This being the nature and these the conditions and tests of the only possible science of Therapeutics, we come now to inquire whether the Old-School Therapeutics are of this nature or will sustain these tests. The works of the foremost men of the Old-School abound in admissions of their lack of a therapeutic law and of the chaotic state of their practice. (1 See Forbes, Bennett, Tod, Holmes and others). But the efforts of these men to remedy this sad state of things show a constant misapprehension of the philosophy of the science they are striving to construct.

We may divide Old-School Therapeutics into two methods. The one bases the plan of cure upon a theory of the nature of the disease, (2 Thus Prof. Geo. T. Elliott in his recent Valedictory to the Graduating class at Bellevue College Hospital says. “In these wards, by those bedsides, have you seen the patient application of the searching analytical laws by which we seek to discover the essentiality of disease”) endeavors so to study the pathology of the diseases as to form a sound hypothesis of its modus operandi and then essays the cure upon “general principles.” It undertakes, in fact, to act in Therapeutics upon what we have seen to be the true method in Hygiene.

There are three objections to this method, any of which would be conclusive were there not a prior difficulty in the simple impossibility of arriving at a knowledge of the nature of the disease, which is modified life. A simple example will show this impossibility. In Pneumonia the blood contains an excess of fibrine. How happens this? Why, either the elimination of fibrine has been retarded or its fabrication has been accelerated. What are the agents of these respective processes? Cells-which are essentially similar in all parts of the body-and yet whose structureless walls possess the power of separating from the circumambient fluids the most diverse substances in different organs-nay, even of manufacturing new substances. Now, until we can learn the secret of this mysterious power of the cell wall, which begins and ends with life, which we can neither comprehend nor imitate nor simulate, we shall not arrive at an understanding of the nature of any disease.

Of the other objections to this method the first two are somewhat paradoxical. The method constitutes rather a congeries of sciences of Therapeutics, based on theories of isolated groups r types of disease, than a single, all-embracing science founded on one comprehensive theory of disease. Hence, a new science must be formed for every new type. It is too special. On the other hand, it is too general to embrace all the phenomena of each individual case. For observation shows incontestably that so great are the varieties of temperament and relative organization and condition among men, that no two cases of the same disease, so to speak, a re exactly alike.

Such a Therapeutics must be necessarily based on a theory which is a generalization, and which therefore overlooks those phenomena of a given case which are peculiar to the individual patient and takes congizance only of those phenomena which are common to a great number of cases. Now, a method which requires such generalization and makes no provision for the strictest individualization is radically vicious.

The eye of science regards natural phenomena with the most absolute impartiality. In her view there are no trifles, no events, subjective or objective, which are “irrelevant” and “of no moment.” A method of Therapeutics, however, which selects a few symptoms, calls them pathognomonic of Pneumonia, constructs upon them a theory of the disease, and from this deduces a mode of cure, must disregard many phenomena of every individual case. It arbitrarily pronounces them “accidental” but Nature knows no accidents.

So far is this method from meeting the requirements of inductive science, that it is not too much to say that this process of generalization actually leads to the treatment of cases which have no real existence and never had any, in fact, to the treatment of abstractions. For who ever saw a case in which none but the pathognomonic symptoms of Pneumonia were present-or of Rheumatism or Dysentery? Who ever saw ideal cases of these diseases? We all see cases which present the pathognomonic symptoms plus certain others peculiar to the individual, but these vary with the individual, and thus make each case different from every other.

We see and treat the Pneumonia or Rheumatism of John Doe or Richard Roe, each of which presents, in addition to the pathognomonic signs of the disease, certain peculiar modifications impressed upon these signs by the temperament and idiosyncrasies of these persons, along with other symptoms peculiar to each. For such an individualization of disease as would give equal (or, as they deserve, higher) rank to these peculiarities of the individual patient, the method under consideration makes no provision. This fallacy was perceived and well exposed by the Leipzic Professor who recently exclaimed to his class: “Gentlemen, we have to do with patients and not with diseases.”

The next objection to this method is that it does not fulfill the first condition of a physical science. It is not capable of infinite progress. This point needs no elaboration. It was fully considered when the condition was stated. In confirmation of what was then said, I need not refer to the successive rise and decline of Brunonism, Broussaisism, the humoral and solid pathology, the theory of the dyscrasias and the reign and decadence of Iron, Iodine, Cod Liver Oil, etc.

The second method of Old-School Therapeutics is the methodical, which discards theory and founds its rules for treating disease upon numerical data, obtained from observation or by experience upon the sick.

Given records of three series of cases, 1,000 in each, and under three modes of treatment: Under treatment A, 500 recovered; under B, 300; under B, 300; under C, 200. A is adopted as the established mode of treatment for the disease- “Risum teneatis, Amici?” An elaborate criticism of this method is unnecessary. It is enough to say that it does no fulfill either condition of a physical science. It is incapable of infinite progress. The addition of 500 cases to the 3,000 above named might modify all conclusions and place treatment C in advance of A or B. There would result a complete revolution in practice and in the direction of investigation.

But it utterly fails to enable us to foresee and provide against new forms of disease. If a thousand or two of cases must be seen and experimented upon, in all conceivable ways, before definite and trustworthy conclusions as to the best treatment can be arrived at, who would not pray that his turn might come among the third or fourth thousand? Who would not pity the victims among the first thousands?

Notwithstanding these obvious objections, this method of constructing a science of Therapeutics upon observation, whether at random or based on experimentation upon the sick, has the sanction of some of the highest names in the profession- among which it is a sufficient to name Louis and Forbes. It demands, therefore, a more extended consideration. As it involves the application of both Mathematics and Logic, the opinion of the highest authorities in these respective sciences should be conclusive as to the soundness of the method, and we content ourselves with quoting two of them:

M. August Comte, one of the first living mathematicians, and who would therefore be disposed to apply mathematical methods to the natural sciences wherever this were possible, expresses himself in the following manner concerning the numerical method in medicine:

“Indeed, the spirit of calculation tends in our day to introduce itself into this study (Physiology), especially into that part of it which relates to medical questions, but far less direct method, under a far more deceptive form, and with infinitely more humble pretensions. I wish to speak of that assumed application of it which is called the Statistics of Medicine, from which so many savants expect great things and which, from its very nature, can lead only to profound and direct degradation of the medical art (which) would be reduced by it to a method of blind enumeration). Such a method, if we may be allowed to call it by the name of method at all, cannot in reality be anything else than absolute empiricism, disguised under the frivolous garb of mathematics.

Pushed to its extreme logical consequences, it will tend to make all rational medication radically disappear from medicine, by conducting the practitioner to make random trials of certain therapeutics measures with the object of nothing down, with minute precision, the numerical results of their application. It is evident, on principle, that the continued variations to which all organism is subject, are necessarily more pronounced in a pathological than in a normal state, and as a consequence of this fact, the cases must be even less exactly similar, whence results the manifest impossibility of making a judicious comparison between two curative methods derived from data, furnished by statistical tables alone, independent of some sound medical theory. No doubt, some direct experimentation, restrained under proper limits, might be a great importance to medicine as well as to Physiology, but it is precisely under the strict condition that it shall never be merely empirical, but shall always attach itself either in institution or in its interpretation to an entire system of corresponding positive doctrines. Notwithstanding the imposing aspect of the forms of exactness, it would be difficult to conceive of an opinion in

Therapeutics more superficial and more uncertain than that which rests solely on the easy computation of fatal and favorable cases, to say nothing of the pernicious practical consequence of such a manner of proceeding when one could not beforehand exclude any kind of attempt. Plus

“It is really deplorable that geometricians have sometimes honored with some kind of encouragement, such a profoundly irrational aberration by making vain and puerile efforts to determine by their illusory theories of chances, the number of cases sufficient to make these statistical results legitimate.” (1 Course de Philosophie Positive, par Mo Auguste Comte, tom. iii., pp. 418- 420).

And with a direct reference to the method of obtaining a correct system of Therapeutics by experimenting with individual medicines and individual cases of diseases, and forming of the results statistical tables from which deductions are to be drawn by the numerical method, the highest modern authority in philosophy, John Stuart Mill, speaks in his System of Logic. (1 Harper’s edition, 1848, p. 260). “Let the subject of inquiry be the conditions of health and disease in the human body; or (for greater simplicity) the conditions of recovery from a given disease; and in order to narrow the question still more, let it be limited, in the first instance, to this one inquiry: Is or is not a particular medicament (Mercury, for instance) a remedy for that disease?

“The experimental method would simply administer Mercury in as many cases as possible, nothing the age, sex, temperament and other peculiarities of bodily constitution, the particular form and variety of the disease, the particular stage of its progress, etc., remarking in which of these cases it produced a salutary effect, and with what circumstances it was on those occasions combined.

“When we devise an experiment to ascertain the effect of a given agent, there are certain precautions which we never, if we can help it, omit. In the first place, we introduce the agent into the midst of a set of circumstances, which we have exactly ascertained. It need hardly be remarked how far this condition if from being realized in any case connected with the phenomena of life; how far we are from knowing what are all the circumstances which pre-exist in any instance in which Mercury is administered to a living being. This difficulty, however, though insuperable in most cases, may not be so in all; there are sometimes (though I should think never in Physiology) concurrences of many causes in which we yet know accurately what the causes are. But when we have got rid of this obstacle, we encounter another still more serious. In other cases, when we intend to try an experiment, we do not reckon it enough that there be no circumstances in the case, the presence of which is unknown to us. We require also that none of the circumstances which we do know of shall have effects susceptible of being confounded with those of the agent whose properties we wish to study. We take the utmost pains to exclude all causes capable of composition with the given cause; or if forced to let in any such causes we take care to make them such that we can compute and allow for their influence, so that the effect of the given cause may, after the subduction of those other effects, be apparent as a residual phenomenon.

“These precautions are inapplicable to such cases as we are now considering. The Mercury of our experiment being tried with an unknown multitude (or let it be a known multitude) of other influencing circumstances, the mere fact of their being influencing circumstances, the mere fact of their being influencing circumstances implies that they disguise the effect of the Mercury, and preclude us from knowing whether it has any effect or no.

“In phenomena so complicated it is questionable if two cases similar in all respects but one ever occurred; and were they to occur we could not possibly know that they were so exactly similar.

“Anything like a scientific use of the method of experiment in these complicated cases is therefore out of the question. We can in the most favourable cases, only discover, by a succession of trails, that a certain cause is very often followed by a certain effects”.